huohuyhup
Obstetric health care use of women in Egypt
Influences of first pregnancy outcomes at obstetric health care use during second pregnancies.
Annemarie Ernsten
Masters thesis Demography Faculty of Spatial Sciences University of Groningen
Obstetric Health care use of women in Egypt
Influences of first pregnancy outcomes at obstetric health care use during second pregnancies.
Annemarie Ernsten
Supervisors: Dr. F. Janssen &
Prof. dr. L.J.G. van Wissen Masters thesis Demography Faculty of Spatial Sciences University of Groningen August 2007
Frontpage: Mother shows her newborn baby.
Photo by author, Cairo 2003.
Abstract
Earlier was the availability of health services in Egyptian healthcare the biggest problem, yet it is the non-usage of the services that is of much concern. To make a change of behavior happen, clear insight in the usage of obstetric health care is essential.
To gain more knowledge of obstetric health care use of Egyptian women and to explore whether the outcome of a first pregnancy influences health care use during a second pregnancy, this study investigates potential differences in obstetric care use of these women throughout their birth-giving career.
Little is written yet on the influence of mortality on health care usage. But regarding health care use, the Socio-Behavioral model of Andersen was constructed to understand why people use health care services. Data of the Egyptian Demographic Health Survey 2005 is analysed by constructing descriptive tabulations and performing log-linear tests and logistic regression models.
The findings of the research show that, when comparing usage of obstetric health care at first and second pregnancy, during second pregnancies less antenatal care was used and fewer deliveries in health facilities were observed. At first pregnancy 70.4 percent of the women used sufficient antenatal care. 42.2 percent delivered in a private facility, 30.6 percent went to a public facility and 24.3 percent delivered at home. At second pregnancy 60.4 percent of the women went for sufficient antenatal care. 38.5 percent delivered in a private facility, 25.6 percent in a public facility and 33.2 percent delivered at home.
The outcome of the first pregnancy has a significant influence on health care use during a second pregnancy. The possible explanation, which first pregnancy outcomes could give about the difference between obstetric care use during first and second pregnancies would be: Most women have positive pregnancy outcomes. Women with positive first pregnancy outcomes use less formal obstetric care during second pregnancies than women whose first pregnancy ended negatively. The difference in health care usage between first and second pregnancies is thus due to women with positive first pregnancy outcomes.
Contents
Acknowledgements ... 5
2 Egypt ... 8
2.1 Generalities... 8
2.2 Economy and education... 8
2.3 Health... 8
3 Theoretical framework ... 10
3.1 Obstetric health care ... 10
3.2 The Socio-Behavioral Model of Andersen... 10
3.3 Previous pregnancy outcomes ... 13
3.4 Conceptual Model... 13
4 Methodology ... 15
4.1 Data and samples ... 15
4.2 Research design ... 16
4.3 Operationalisation... 18
5 Obstetric health care use at first and second pregnancy... 20
5.1 Antenatal care during first pregnancy ... 20
5.2 Delivery care at first pregnancy... 22
5.3 Antenatal care during second pregnancy... 25
5.4 Delivery care during second pregnancy ... 26
5.5 Similarities and differences ... 29
5.5.1 Antenatal care... 29
5.5.2 Delivery care ... 30
6 Health care use according to first pregnancy outcomes... 32
6.1 Antenatal care ... 33
6.2 Delivery care... 35
7 Conclusions and recommendations ... 38
7.1 Conclusions ... 38
7.1.1 First pregnancies ... 38
7.1.2 Second pregnancies ... 39
7.1.3 First and second pregnancies... 40
7.1.4 Influences ... 41
7.2 Discussion... 42
7.3 Recommendations ... 43
References... 45
Tables and Figures
Table 4.1 Sample information 15
Table 5.1 Antenatal care at first pregnancy by predisposing characteristics of the
mother 21
Table 5.2 Antenatal care at first pregnancy by enabling resources of the mother 22 Table 5.3 Delivery care at first pregnancy by predisposing characteristics of the
mother 23
Table 5.4 Delivery care at first pregnancy by enabling resources of the mother 24 Table 5.5 Antenatal care at second pregnancy by predisposing characteristics of
the mother 25
Table 5.6 Antenatal care at second pregnancy by enabling resources of the mother 26 Table 5.7 Delivery care at second pregnancy by predisposing characteristics of
the mother 27
Table 5.8 Delivery care at second pregnancy by enabling resources of the mother 28 Table 6.1 Second pregnancy, having information about both pregnancies 32 Table 6.2 Results of the logistic regression, dependent variable antenatal care use 33 Table 6.3 Change in antenatal care use during second pregnancy by outcome of
first pregnancy 35
Table 6.4 Results of the logistic regression, dependent variable is use of medical
delivery care 36
Table 6.5 Change in delivery care use at second pregnancy by outcome of first
pregnancy 37
Figure 3.1 Initial Behavioral Model of Andersen 11
Figure 3.2 Conceptual model 13
Figure 5.1 Antenatal care at first pregnancy 20
Figure 5.2 Place and attendant at first pregnancy 22
Figure 5.3 Antenatal care at second pregnancy 25
Figure 5.4 Delivery care at second pregnancy 27
Figure 5.5 Antenatal care 30
Figure 5.6 Delivery care 31
Figure 6.1 Outcome of the first pregnancy 32
Acknowledgements
In 2003 I spent four months living and studying in Cairo. During these months I travelled through most of Egypt and saw the country's large differences in spatial development and people’s wealth. Of course I knew on forehead that this country varied from my own but it feels different when you are actually there. I still remember the shock when I first met a woman of my age, who could not read or write. I took this experience as an inspiration for this thesis
This year I started the Masters of Human Population Studies. I decided to combine my knowledge about Egypt with the subjects I was going to learn about demography;. These two perspections combined made the subject for my Masters thesis: Obstetric health care use of women in Egypt.
I am grateful to my first supervisor Fanny Janssen. The cooperation was very pleasant.
Furthermore she motivated me and her criticism and comments were of great value to the improvement of my research. I would also like to thank my second supervisor Leo van Wissen, for his comments on the statistical analyses.
Sjoerd Kroon and Christian Ernsten made me very happy when they both offered to read my thesis and to give comments. I greatly appreciated their afford.
Finally I would like to thank my parents and friends for their valuable comments and suggestions.
Annemarie Ernsten, August 2007
1 Introduction
In Egypt the common idea about pregnancy is that both pregnancy and giving birth are natural processes of human live and therefore people tend to think that medical involvement is not necessary. Many women believe that the problems they experience are normal female inconveniences and because of this reason they do not visit an attendant.
As a result, small problems can become major ones (UN, 2002).
Mainly due to the national family planning program, a rapid fertility decline has taken place since the 1980s. In 2005 the total fertility rate was 3.1 children per woman. Also infant and maternal mortality rates did decrease. The infant mortality rate (IMR) is now 28 per thousand, while the average IMR in the sub-Saharan countries is about 100 per thousand (UNICEF, 2006). The maternal mortality dropped from 173 per thousand in 1993 to 84 per thousand in 2000, but of these still 92 percent could have been prevented (UN, 2002).
From 1997 until the year 2000 the Egyptian ministry of Health and Population developed the Healthy Egyptians 2010 approach. Healthy Egyptians 2010 is a strategy for the national public health. It is meant to prevent diseases and to promote health, and it is based upon the Health for All approach from the World Health Organization (MOHP, Healthy Egyptians 2010).
To achieve health for all in Egypt, several national goals and objectives were set and four focus areas were chosen. Maternal and Child health is one of the areas, which will be given priority (El-Henawy, 2000). Out of the goals and objectives several strategies were developed. The strategies to improve maternal and child health include acceptance of safe motherhood, by putting stress on early and continuous antenatal care and skilled attendants during delivery as well as family planning services to assure suitable contraception and birth-spacing. The target for maternal mortality is to reduce it to no more than 50 per 100,000 live birth’s by 2010 (MOHP, Healthy Egyptians 2010).
The Egyptian government has far reaching plans to improve maternal and child health.
But although in the past the availability of health care services in Egyptian healthcare was the biggest problem, nowadays it is the non-usage of the services that is of much concern (UN, 2002). To make a change of this behavior happen, a clear insight in the use of obstetric health care is essential (Hausmann-Muela et al, 2003).
This study investigates potential differences in obstetric health care use of Egyptian women throughout their birth-giving career. It is examined whether positive and negative outcomes of first pregnancies influence the health care use of women who are pregnant for the second time. The objective of the research is to gain more insight in the obstetric health care use of Egyptian women and to explore whether the outcome of a first pregnancy influences health care use during a second pregnancy.
Earlier research already has shown that health care use is dependent on personal
circumstances and social well being. And from the various UN and USAID reports it is clear that the proportion of deliveries attended by skilled health personal has increased (UN, 2006). But what has not been examined yet are the differences between pregnancies
of varying order and the influences of earlier pregnancies outcomes. The research presented here makes a start filling these gaps.
To collect more knowledge of the obstetric health care women use in general, the first research questions are:
Which obstetric health care is used by Egyptian women, while being pregnant for the first time, according to their characteristics?
Which obstetric health care is used by Egyptian women, while having their second pregnancy, according to their characteristics?
The answers of the foregoing and next questions will be gained from data of the Egyptian Demographic Health Survey, which was held in 2005. A comparison of these answers will lead to the answer to the next question, which is:
Are there any apparent differences in the obstetric health care use of women who have their first pregnancy and women who have their second pregnancy?
The answers to the previous questions will provide a lot of information regarding obstetric health care use of women in general, and especially, during first and second pregnancy. Another aim of the study is to explore whether previous pregnancy outcomes influence the obstetric health care use during the next pregnancy. For this reason, the next set of questions deal with second pregnancies, namely:
Do the outcomes of the first pregnancy influence the use of obstetric health care when having a second pregnancy?
Do first pregnancy outcomes explain the potential difference between obstetric health care use of first and second pregnancies?
After this introduction, the second chapter will provide some background information regarding the studied population and the context of this study. The third chapter will explain the theory and secondary literature concerning health care use, obstetric health care and previous pregnancy outcomes which a woman can experience. Finally, these theories will be combined into a conceptual framework. The fourth chapter will elaborate on the methodology, which has been applied to find the answers to the research questions. The explanation will give more insight into the data and the definitions of concepts used throughout this dissertation. This information is essential in order to understand the results of the research. Then, the fifth and sixth chapter will give the results according to the research questions. The fifth chapter explains the obstetric health care use during first and second pregnancies. The sixth chapter elaborates on the question whether first pregnancy outcomes influence health care use during second pregnancies.
This chapter will also discuss whether pregnancy outcomes explain the differences in obstetric health care use between first and second pregnancies. Finally, in a conclusive chapter the overall answers and conclusions will be given.
2 Egypt
This chapter will describe the social, economic and health situation in Egypt. Knowledge about these features gives a better understanding of the problem which Egyptian women face. Furthermore, it is impossible to get good insight in the usage of obstetric health care without having knowledge of their living environment (Hardee 2004, Hausmann-Muela, 2003).
2.1 Generalities
Egypt is a country located in the North-East of Africa. In 2006 the population was already over 78 million and the population has a growth rate of 2.1 percent (World bank, 2004). The country size is about 1 million square kilometres but of these only six percent is inhabitable. This makes the liveable places extremely high populated. Forty percent of the people live in urban areas, of which Cairo and Alexandria are the most popular. Cairo has areas in which the number of people per square kilometre exceeds 100.000 (WHO, 2005).
The official religion in Egypt is Islam. By far the most people are Sunni-Muslims, but also much apparent is Sufism, which is a more mystical subgroup within Islam. The only other religion of mentionable size in Egypt is Christianity; most Christian people belong to the Coptic Church (Goldschmidt, 2007).
2.2 Economy and education
Having a gross national income of $1500 per capita, Egypt is a lower-middle income country. Its main sources of income are tourism, earnings from the Suez Canal, oil and remittances (UN, 2002). Because the labor market is not growing with the same speed as is the population the unemployment is relatively high. Officially, it is said to be about 9 percent, but it is believed to be much higher (World bank, 2004). For women this number is definitely much higher. Still there is a big gap in the labor participation of women and men. Although the Egyptian constitution gives women and men the same rights this is not always visible in society. Women are behind in economic participation, getting access to education as well as in getting access to health care services (UN, 2002).
The educational system is also facing the problems of the growing population. Sixty percent of Egypt's adult female population is still illiterate, although this number is decreasing. Education is freely available for all people in Egypt and the law protects the right at education. But the educational system needs a reform to reduce school drop out and increase the quality of the lessons (UN 2002; Beamish 2003).
2.3 Health
Early in the 1920’s Egypt started building maternal and child healthcare centres in the urban areas and on the country side rural health facilities were set up. The public health care became geographically well spread and today the basic health services are accessible for almost the entire population. Ninety-five percent of the population lives within five kilometre of a health facility (WHO, 2005).
The Ministry of Health and Population services and academic clinics and hospitals are publicly accessible. Unfortunately these services do not automatically include care
focussed at reproductive health. Moreover, public facilities are often of poor quality. The public facilities are responsible for a majority of the reproductive health services. The right of women to medical, physical, psychological and social health care is protected in the Egyptian constitution. In addition to this, the National Council for Childhood and Motherhood was established in the eighties (Beamish, 2003).
The legal age for marriage for women is 16 and for men 18 years old. Once married there is a strong social pressure at the couple to start reproducing and as such to prove their fertility. This results in an average age at first birth for women of 20 years old in rural areas and 23 in urban areas. At the age of 19, over 20 percent of the married women have already given birth to a child (Beamish, 2003).
3 Theoretical framework
In order to find a sufficient answer to the research questions, which were presented in the introduction, more information regarding the theory and secondary literature concerning the subject is necessary. I will use the socio-behavioral model of Andersen to get insight in what determinates obstetric health care use. Through this model, insights in the problematic areas of health care use of the women in this research will be derived. Before the discussion of this model, a paragraph (3.1) will be devoted to the contents of obstetric health care. I will reflect on theories regarding previous pregnancy outcomes in paragraph 3.3. Together these theories will lead to the conceptual model, which is shown in the fourth paragraph.
3.1 Obstetric health care
What is involved in obstetric health care? Obstetric health care is all health care from the beginning of the pregnancy up to about two weeks after labor. Ideally the obstetric health care involves antenatal examinations, meaning the presence of skilled attendants at delivery and post delivery executing examinations of mothers and children.
During the antenatal examinations screenings and tests are done in order to determine anaemia and hypertension, as well as for sexual transmitted diseases. If problems are detected the necessary treatment should be provided. The antenatal visit is also a moment that a pregnant woman receives information about diets and where to seek care in case of pregnancy complications (POLICY Project, 2005).
Skilled attendants during delivery are necessary because in case of complications a trained attendant can recognize these and treat them or send a woman to a health facility.
Increasing the number of deliveries assisted by a skilled attendant is a very important factor to reduce maternal mortality (UN, 2006).
Post delivery care involves an examination of the mother of the newborns to detect and to treat possible problems that occur after delivery. Also the health of the child will be checked. Furthermore, at this moment information about caring, breastfeeding, immunization and family planning can be provided and gained (POLICY Project, 2005).
3.2 The Socio-Behavioral Model of Andersen
To gain more insight in the obstetric health care use of Egyptian women and to
investigate potential differences in obstetric health care use throughout their birth-giving career a model for health seeking behavior will be used. This paragraph will give a short explanation about the health seeking models. The model which is most suitable for this research, will be explained more in detail. The most used behavioral models for health care seeking in psychology are the Health Belief Model, the Theory of Reasoned Action of Fishbein and Ajzen and the Theory of Planned Behavior of Ajzen, and for medical sociology and anthropology the Health Care Utilization Model of Andersen (Hausmann- Muela, 2003).
The Health Belief Model was developed by a group of social psychologist in the 1950s.
This model explained people’s behavior, in relation to health. The components of the model are mainly cognitive variables which are measures of perceptions about the disease, the treatment and so on (Janz et al. 2002). The components of the Health Belief Model are proven to be of influence in health behavior. The model is particularly useful
to determine findings for intervention programs (Hausmann-Muela, 2003).
According to Ajzen and Fishbein’s Theory of Reasoned Action, people’s behavior stems from two things. Firstly, how a person feels about performing a certain action and, secondly, what other people think about them doing that action. Ajzen and Fishbein argue, in their Theory of Reasoned Action, that socio-economic and demographic factors only influence behavior indirectly (Stead, 1985). Ajzen also developed the Theory of Planned Behavior. In this theory he tried to include the fact that although people make choices it is not always their free will to act as they do. Both the Theory of Reasoned Action and the Theory of Planned Behavior indicate that behavior can be predicted from an intention to behavior (Orbell, 1997).
The advantage of these models is that they both take aspects of a person’s motivation to do a certain action into account. Yet there has not been paid much attention to socio- economic and demographic aspects, as these are indirect causes of the intention (Stead, 1985; Haussmann-Muela, 2003).
All previous mentioned models and theories have their advantages and disadvantages, but the one that fits this research best is the Socio-Behavioral model of Andersen. The model is also called the behavioral model of health services use and was developed by the American sociologist Andersen in 1968. It was specially constructed to understand why people use health care services. The model was meant to predict and to explain health services use (Andersen, 1995; Hausmann-Muela, 2003). Andersen's model describes health care use as a function of predisposing, enabling and need variables. The model is used during many researches and there have been many versions of the model (Kroeger, 1983). The version as Andersen initially developed it is shown in figure 3.1.
Andersen developed his model initially to explain health care use in the United States.
But usage of the model during numerous researches in developing countries showed that it is also there very usefull (Weller et al. 1997).
According to the model, health care use is dependent on several factors: people’s need for health services, their ability to use care and their predisposition to do so. The importance of these factors is in the same order. When there is no need for health care the enabling resources are also less important. When there is no ability to receive health care the predisposing characteristics are meaningless.
The factor which is going to be explained is health care use. According to Andersen, the first factor which can cause the use of care is ‘need’. As is shown in figure 3.1 the need is
Predisposing Enabling Need Health care
Characteristics resources use
Demographic Personal/Family Perceived Social Structure Community (Evaluated) Health Beliefs
Figure 3.1 Initial Behavioral Model of Andersen
Source: Andersen (1995)
divided into two categories. The first one is the perceived need, which involves how people view their own health. In this their own experience of pain and symptoms of sickness, which let them experience need. The second category is the evaluated need.
This need represents professional judgment of the need of people to use health facilities.
The evaluated need is more or less the same for every person with the same sickpattern while the perceived need can be different per person (Andersen, 1995).
If need is apparent the enabling resources become important. The health care use of an individual is dependent on the social, economic and demographic characteristics of the family a person belongs to (Andersen, 1995).
The community, family and personal level of ability must be present to make the use of health care possible. At the community level health personnel and facilities must be available. At the family and personal level, people need to know how to get to a health facility and they must have the financial means and the knowledge to obtain certain health services. Thus income is important in this matter (Andersen, 1995).
When a person has the ability and the need to seek health care, the predisposing characteristics will also influence this person’s health care seeking behavior. The predisposing characteristics contain three main categories: demographic characteristics, social structure and health beliefs (Andersen, 1995).
In terms of demographic characteristics, the age and gender of a person indicates the likelyhood that the person needs healthcare. Social structure has to do with the status a person has in the community, mostly including education, occupation and ethnicity (Andersen, 1995). Also Kroeger found in his research on anthropological and socio- medical health care research in developing countries that ‘formal education turned villagers away from traditional healing’ (Kroeger, 1983, p.150).
Health beliefs are defined as attitudes, values and knowledge, which people have about health services. These can influence their perceptions of the need of health care and the use of health facilities (Andersen, 1995).
After Andersen developed the initial model a lot of critique in relation to the different phases in the model were given. Much of the critiques were about missing variables or about definitions, which were to broad. Andersen assessed these critiques and made new models in which he included some of the variables. I like to bring in remembrance the fact that Andersen meant his model to predict and to explain health services use. Yet it appeared that most of the critiques were given when the model was aimed for the prediction of health care use. Furthermore the comments were very much depending of the type of utilization, which was to be studied. This makes the model still very suitable for this research (Andersen 1995).
However some aspects of the model still could be improved. For this reason, Phillips et al. (1998) studied a number of researches at health care utilization, which made use of Andersen's model during the last twenty years. Phillips and his colleagues studied whether extra variables were included in Andersen’s model and if so, what kind of variables. They found that forty-five percent of the studies they examined included environmental variables and fifty-one percent included provider-related variables.
3.3 Previous pregnancy outcomes
Do positive and negative pregnancy outcomes influence health care use during a second pregnancy? Or does death influence health care use? After an intensive literature research it becomes clear that most research is done on how health care use reduces mortality.
Nothing was found accounting to the specific topics of this thesis, probably because it has not or very little been researched.
Also literature considering risk assessment did not give results which could be used to explain the influence of previous pregnancy outcomes at the usage of obstetric health care. I did find examinations, which include the subject of previous experiences in general. Several psyhological magazines go into this subject. Both Christie (2007) and Tversky and Kahneman (1983) mention that current actions are always influenced by experiences and knowledge of a person. Tversky and Kahneman researched intuitive reasoning. Humans assess probabilities of an event to take place according to the knowledge and beliefs they have, they will always search for similar situations (Tversky and Kahneman, 1983). Christie (2007) researched the influence of evaluations on actions of decision makers. In the article it is stated that changes that occur in a human’s knowledge, attitudes and opinions are influencing that persons actions.
So, according to these two researches it can be said that having a different past experience probably means that the action, which will be taken, concerning the use of certain health care provisions can also differ.
3.4 Conceptual Model
The conceptual model derived from the previous discussed theories and secondary literature is displayed in figure 3.2. It shows the relationships between health care use, and the different characteristics of the women. The model of Andersen can still be recognized, although there have been some modifications.
Of course obstetric health care use is the factor, which is going to be explained, it is subdivided into antenatal care and delivery care. Andersen used in his initial model a certain sequence of the different factors, but he mentioned that this sequence was mainly of use when the model was aimed for prediction purposes (Andersen 1995). Also Hausmann-Muela et al. (2003) says that it is not always necessary to order the variables.
Use obstetric health care
- Antenatal - Delivery Predisposing characteristics
- Education - Age at birth - Religion Enabling resources
- Wealth
- Type of residence
Previous pregnancy outcome - First pregnancy outcome Figure 3.2 Conceptual model
During this research on obstetric health care use there is no need for the order of factors because the purpose of the model is to explain rather than to predict health care use.
The ‘need’ factor is left out of the conceptual model. Since with each pregnancy and delivery there is a risk for mother and child (Khalil and Roudi-Fahimi, 2004; WHO, 1994) and therefore each pregnancy needs some form of health care. The need is apparent in all cases in our research population.
As the previous pregnancy outcomes are the main issue of research, this has become a separate factor next to predisposing characteristics and enabling resources. The predisposing characteristics, the enabling resources and previous pregnancy outcomes can all influence the probability that a woman receives the care she needs. The predisposing characteristics in the conceptual model contain education of the mother. Her age during delivery of the child and her religion. And the enabling resources are wealth and type of residence. It is also possible that the previous characteristics and enabling resources influence the outcome of the first pregnancy.
4 Methodology
In the next chapter I give a description of my research. This description starts with a paragraph on the data and the samples, which were used for the study. Than a section will be devoted to the research questions and the method of analysis, which will be applied to the various question. The last paragraph will explain the concepts and elaborates on how these concepts are operationalised during in the research.
4.1 Data and samples
According to Weller et al (1997), Andersen's model of health care utilization is highly useful when working with statistical data. The data used for this research is derived from the Egyptian Demographic Health Survey 2005 (E-DHS). A Demographic Health Survey provides a cross-sectional, nationally representative range of information about all kinds of subjects linked at health population and nutrition (MEASURE DHS, 2006). The main purpose of this DHS was to provide information on family planning, fertility, infant and child mortality, and information on health and nutrition of mother and child (El-Zanaty and Way, 2006).
The study population consists of mothers of whom information about their pregnancies are included in the maternity section of the E-DHS. They all have had a first or a second pregnancy. The maternity section is part of the individual recode file, in which data of 19747 ever-married women age 15-49 is stored. Information is collected about the care women received during pregnancy and the reasons why they sought care (El-Zanaty and Way, 2006).
In the maternity section health information is provided about all pregnancies and births that took place in the five years previous to the survey. Unfortunately the section does not give information about the care used in case a pregnancy was terminated without a delivery. This, and to oppose small sample sizes, are the reasons why different samples are used during the study.
For the whole study three samples are used, which are shown in table 4.1. Best would be to use only one sample for all research questions. This sample should contain a large number of women of whom information was available of their first and second pregnancy. Nevertheless the DHS does not provide such a sample. This is why three different samples of women are used, to create as largest numbers of mothers as possible.
One sample exists of women that had their first pregnancy in the five years preceding the demographic health survey. The second sample consists women who had their second pregnancy in the five years preceding the survey and the third sample contains women who had their first ánd their second pregnancy in these years.
The first sample includes 3741 women. They all had their first pregnancy, which ended into giving birth to a child. The second sample consists of 3429 women, who all had a
Table 4.1 Sample information
Information about:
Sample N Pregnancy Possible termination during first pregnancy included in the sample
1 3741 First No
2 3429 Second Yes
3 1531 First and second No
second pregnancy in the five years preceding the demographic health survey. Of them, 2983 had a first pregnancy which outcome was positive. The other 446 women had a pregnancy that was terminated or their child died during or after pregnancy. These terminated pregnancies were included because considering health care use at pregnancy, the DHS provides most information about the antenatal care period. Most women who have had a terminated pregnancy, could have already had or actually had antenatal care examinations.
In the third sample in table 4.1, women are included who had their first and their second pregnancy in the five years previous to the survey. This is the smallest sample. It consists of in total 1531 women for 1476 of them their first child survived through pregnancy and delivery while 55 of the children did not survive. In this sample no women with a terminated pregnancy are included.
4.2 Research design
The objective of this research is to gain insight in the differences in health care use of pregnant women in Egypt, while having their first or second pregnancy. In addition, I aim to explore whether different outcomes of a first pregnancy influence health care use at second pregnancy. To reach the objective, specific information needs to be obtained.
Firstly some descriptive questions will be answered. These questions will focus on the obstetric health care and the determinants influencing this kind of health care. Later the first pregnancy outcomes will be included.
To explain if women use health care during second pregnancies in the same way as they did during the previous pregnancies, knowledge is needed concerning the obstetric health care they used regarding the pregnancies separately. This leads to the first research question:
Which obstetric health care is used by Egyptian women, while being pregnant for the first time, according to their characteristics?
To obtain the answer to this question, information is needed about women with a first pregnancy. The E-DHS does not provide healthcare use information when a pregnancy was terminated. Therefore, only women who actually did give birth after their first pregnancy are included in the sample, which is the first in table 4.1.
A different sample is needed to obtain the answer at the question:
Which obstetric health care is used by Egyptian women, while having their second pregnancy, according to their characteristics?
To answer this question the second sample of women, who had a second pregnancy in table 4.1, was used. The sample does not contain women whose second pregnancy was terminated without a birth.
The two foregoing questions are answered in descriptive tables. In these tables the predisposing characteristics and enabling resources are set against health care use. The tables are chosen as way of showing the results because they easily provide knowledge about how the use of obstetric health care is distributed over the women with different
characteristics. Comparing the results of the questions about first pregnancies with the results of the questions about second pregnancies leads to the answer at the next question, which is:
Are there any apparent differences in the obstetric health care use of women who have their first pregnancy and women who have their second pregnancy?
By answering the previous questions information will be gained about obstetric health care use of women in general and specifically for the first and second pregnancy. The aim of the research done in this thesis is to find out if and how first pregnancy outcomes influence the obstetric health care use. Firstly, I analyse if the outcomes have an influence. The question derived from this is:
Do the outcomes of the first pregnancy influence the use of obstetric health care when having a second pregnancy?
The influence of the first pregnancy outcomes will be tested through the usage of a regression model. Firstly, a log linear test is done to detect the structure in the data, than a logistic regression model will be used to explain the outcomes. The women in the sample, which is the second in table 4.1, had a first pregnancy, which could either end in a birth or end in a termination. All of these women had a second pregnancy, which ended in a birth.
The log-linear test was especially done to examine whether not only health care use was influenced by first pregnancy outcomes but, also if first pregnancy outcomes were influenced by the predisposing and enabling characteristics. During the log-linear analysis tests were done with three variables at the time. Health care use, first pregnancy outcome and one of the other characteristics were researched for associations, this was done with all the predisposing characteristics and enabling resources.
The logistic regression models probabilities, it gives the likelihood that a certain action will take place. The model made for this research, includes first pregnancy outcomes, all characteristics and all the associations found in the log linear test. The dependent variable in the logistic test is health care use. It gives a model that explains if and how health care use dependents on the first pregnancies outcome and the characteristics.
The used model has the form of: ( )
1
1 0
1 e β βx
π − +
= + Because this is difficult to handle the model will be used in a log odds form, which looks like:
k kΧ + + Χ + Χ +
=
⎟⎠
⎜ ⎞
⎝
⎛
− β β β β
π
π ...
log 1 0 1 1 2 2
Where π is the probability that a woman used health care during pregnancy,β0 is a constant factor of health care use, Χ1−k are the independent variables and β1−k the coefficients of the independent variables.
By now knowledge concerning the questions whether first pregnancy outcomes influence obstetric care use at second pregnancy is obtained. The next thing to research is the way
in which first pregnancy outcomes influence health care use. This leads to the last research question:
Do first pregnancy outcomes explain the potential difference between obstetric health care use of first and second pregnancies?
Health care use during first and during second pregnancy is compared per woman. A new variable is made to measure this difference. To create such a variable information is needed about the first and second pregnancy of a woman. For this reason the third sample in table 4.1, which includes the needed information, is used. In this sample the possible first pregnancy outcomes are survival or death. The results of the research question are visible in a cross tabulation, which shows the new variable of difference by the first pregnancies outcomes.
4.3 Operationalisation
This paragraph gives a link between the possibilities of the DHS-data and the needs of the conceptual model. Here I explain in which way the definitions in the conceptual model are used during this study.
Obstetric health care use is defined as all care, which takes place from the beginning of the pregnancy including the delivery and the maternity time afterwards. There are three periods in this health care, namely the prenatal, delivery and postnatal period (IGZ, 2003). The obstetric health care in these periods is called prenatal / antenatal care, delivery care and postnatal care. This research focuses on the prenatal and delivery period, and has therefore two variables of care. Antenatal care and Delivery care.
• Antenatal care
The WHO has developed a model for antenatal care. In this model four antenatal visits are recommended for women without any specific needs (2001). The DHS provides information about the number of antenatal visits. The categories of the variable antenatal care are divided in two groups, consistent of four or more, or less than four visits during the antenatal period.
• Delivery care
In terms of health care during delivery, the person who assists during delivery and the place where the delivery take place are very important. A skilled assistant at delivery can detect potential problems early and treat them or send the woman to a health facility.
When a delivery takes place at a health facility and a problem occurs, help is nearby.
In the DHS questions are asked about who assisted during delivery. The possible assistants were the doctor, the nurse or midwife, the traditional midwife (daya), the family and no one. Women could give more than one answer, this is why only the highest skilled attendant is counted.
Because many places were mentioned, when in the DHS, the question was raised where a delivery had taken place, they were divided into different categories: homes, public facilities, private facilities and other places.
Predisposing characteristics are personal features of the women in the research population (Andersen, 1995). Three important characteristics are used in this research: education, age and religion.
• Education
In the survey, questions were asked about the highest level of education attended, the highest level of education completed and the number of years of education received. For this research I use the variable about highest level of education attended, which groups the educational achievements into four categories. These categories are: no education, primary education, secondary education and higher education.
• Age at birth
The age of the mother, at the moment the pregnancy ended in a birth, will be considered when mentioned the age at birth. The ages are combined in different age groups.
• Religion
A question in the demographic health survey asks the respondents whether they are Muslim or Christian. These answers are also used during the current research.
Enabling resources were conceptualised as the availability of health facilities and the financial means to obtain health care (Andersen, 1995). Ideally, the enabling resources would be operationalised by a variable about personal wealth/income and the presence of health facilities and personnel.
• Wealth
A variable of income is apparent in the Demographic Health Survey for this research.
This is a variable of wealth which, categorises the respondents into five categories;
poorest; poorer; middle; richer and richest.
• Type of place of residence
No questions were asked about the availability of services unless a women did not make use of any kind of healthcare. But according to the WHO (2005) 95 percent of the Egyptian population lives within five kilometre of a health facility. So a distinction is made between the women living in a rural area and them living in an urban type of residence.
Previous pregnancy outcomes are defined as the outcome of the first pregnancy.
• First pregnancy outcome
Different categories can be measured according to the first pregnancy outcomes. A positive pregnancy outcome means that during pregnancy and after delivery the child survived for at least two months. In the category entitled negative pregnancy outcome, I include terminated pregnancies and babies who died before, during, or within two months after delivery. The possible answers are: positive versus negative and survival versus death, where death does not include terminated pregnancies.
5 Obstetric health care use at first and second pregnancy
This chapter focuses on the general obstetric health care use of women in Egypt. I will give the descriptive results of the first three research questions. These were:
Which obstetric health care is used by Egyptian women, while being pregnant for the first time, according to their characteristics?
Which obstetric health care is used by Egyptian women, while having their second pregnancy, according to their characteristics?
Are differences apparent?
To gain an answer to these questions the general use of prenatal and delivery care during pregnancy will be discussed. Cross tabulations were made to examine the obstetric health care use according to the predisposing characteristics and enabling resources. Finally the results of first and second pregnancy will be compared.
5.1 Antenatal care during first pregnancy
The variable about antenatal care during first pregnancy assesses the number of antenatal visits during a pregnancy. According to the WHO (2001), women with normal pregnancies need at least four antenatal care check ups. When a woman had four or more antenatal check ups, antenatal care is regarded to be sufficient. Most of the women who did go for four or more check ups, 99.8 percent, received the antenatal care from a doctor.
In Figure 5.1, the percentages of women who did, and who did not receive sufficient
antenatal care, are shown. From the sample of 3696 women 29.6 percent did not receive sufficient antenatal care during their first pregnancy. This means that 70.4 percent did have at least four antenatal visits.
Table 5.1 gives information about the use of antenatal care during first pregnancy according to the different predisposing characteristics. Looking at the observations there could be a link between education and the use of antenatal care. Most of the women who did not receive sufficient antenatal care during first pregnancy are the women who are not educated. In the group of women who are reported to have had some education, the proportion that also was reported to receive sufficient antenatal care is 20 percent points larger than that of the uneducated group. Considering antenatal care during first
4+ visits -4 visits
80 70 60 50 40 30 20 10 0
Percent
29,6
70,4
Figure 5.1 Antenatal care at first pregnancy N=3696
pregnancy there is a difference of almost 50 percent points between the lowest and highest educated women.
The youngest age at first birth was reported by a person of 14 years old at that time. The youngest age category, in which women from 14 till 20 years are included, received less antenatal care than the other groups. Of the women who were between 14 and 20 years old at the time of their first birth, 58 percent are reported to have had four of more antenatal check ups during her first pregnancy. This percentage rises until the age category 25-29 at age first birth. The category of women being 30 years or older are reported to receive sufficient antenatal care during first pregnancy in 80.2 percent of the cases. This is 3.1 points less than the 25 till 30 years age group.
The E-DHS 2005 only mentioned two possible answers when asking the women about their religion. A woman was either Muslim (94.9 %) or Christian (5.1 %). The proportion of Christian women who are reported to receive sufficient antenatal care was 1.1 percent points higher than the proportion of Muslim women giving this answer.
The enabling resources indicate the ability of a woman to seek care according to her wealth and her place of residence she lives in. Table 5.2 represents the antenatal care during first pregnancy by the different enabling resources.
The observations, which represent the wealth of a woman by the antenatal care seem to show a pattern. The poorest group in the wealth index received least antenatal care while the richest group received most. The biggest differences are between the poorest and poorer, 16.7 percent points, and the middle and richer group, 14.1 percent points.
Comparing the poorest and richest groups in the wealth index the percentage of people receiving antenatal care is 50 percent points higher for the women in the richest group.
Table 5.1 Antenatal care at first pregnancy by predisposing characteristics of the mother N = 3696
Total Antenatal care first preg
-4 visits 4+ visits
Predisposing characteristics N % %
No education 867 56,4 43,6
Primary 365 37,5 62,5
Secondary 1972 22,0 78,0
Highest educational level
Higher 492 7,3 92,7
14 – 19 1105 42,0 58,0
20 – 24 1826 27,3 72,7
25 – 29 603 16,7 83,3
Age at birth
30+ 162 19,8 80,2
Muslim 3507 29,7 70,3
Religion
Christian 185 28,6 71,4
Missing 4 . .
Total 3696 29,6 70,4
Women living in an urban area are reported to receive antenatal care in 85.4 percent of the cases. From the women in rural areas only 60.2 percent is reported to have received antenatal care during their first pregnancy. This is a difference of more than 25 percent points, while both groups are supposed to have access to health facilities (WHO, 2005).
Both enabling resources, wealth and type of place of residence show a difference between being in a certain category and the proportion of women who received antenatal care during first pregnancy.
5.2 Delivery care at first pregnancy
The second measurement of obstetric health care use is the care obtained during delivery.
The places of delivery can be at home, in a public health facility or in a private health facility. When a woman delivered in a public or private health facility she was nearly always assisted by a doctor. In case a woman delivered at home she was either assisted by a daya, which is the traditional birth attendant in Egypt, or by a doctor, nurse or midwife.
Figure 5.2 shows the distribution over the different places and attendants at delivery. 15.9 percent of the women delivering their first child, delivered at home with a daya assisting and 8.4 percent gave birth at home while a skilled medical person was present. In total this means that 24.3 percent of the women gave birth to their first child at home, 30.6
Other home, nurse/mid wife/doctor home,
traditional attendant private
sector doctor public sector doctor
50 40 30 20 10 0
Percent
8,4 2,7 15,9 42,4 30,6
Figure 5.2 Place and attendant at first delivery N= 3741
Table 5.2 Antenatal care at first pregnancy by enabling resources of the mother N = 3696
Total Antenatal care first preg
-4vistis 4+ visits
Enabling Resources N % %
Poorest 712 57,7 42,3
Poorer 747 41,0 59,0
Middle 750 30,1 69,9
Richer 797 14,2 85,8
Wealth index
Richest 690 5,7 94,3
Urban 1491 14,6 85,4
Type of place
of residence Rural 2205 39,8 60,2
Total 3696 29,6 70,4
percent delivered in a public health facility and 42.4 percent delivered in a private facility. These numbers seem to indicate that woman prefer to deliver at a private facility.
Over 80 percent of the women in the study population delivered their first child while a trained medical person assisted them.
Home deliveries are in general considered to be less favourable than deliveries in a health facility. Because if medical intervention is needed this is not directly around in a home. A case study done in an Egyptian academic hospital (public facility) by El-Nemer et al.
(2006) showed worrying observations about hospital deliveries. The women in this study are often reported to have said that they had the feeling that they were not treated as a person. Some of the women included in this research did not want to deliver in a hospital again, although they are aware of the risk of home deliveries (El-Nemer, 2006).
In table 5.3, the place and attendant at first delivery by the predisposing characteristics are shown. In this table the secondary and higher educated women show the largest proportions for the delivery in a private facility. 66.5 percent of the higher educated women and 46.0 of the secondary educated delivered there. Most of the primary educated woman, namely 37.7 percent, delivered in a health facility in the public sector.
Most of the women without education delivered at home. About 31.4 percent delivered at home with a traditional birth attendant. The higher educated women not often delivered at home, 4 percent are reported to have had a home delivery with a daya and 3.6 percent of them said to have delivered at home with a medically trained attendant.
Delivery in a public facility appears to be most popular among older women. The older the age group, the bigger is the percentage of women delivering in a public facility. The opposite is the case with home deliveries. The older is the age group, the smaller is the
Table 5.3 Delivery care at pregnancy by predisposing characteristics of the mother N = 3741
Total Place and attendant at first delivery
Public sector, doctor
Private sector, doctor
Home, traditional attendant
Home, medical
attendant Other
Predisposing characteristics N % % % % %
No education 876 28,8 27,1 31,4 9,8 3,0
Primary 396 37,7 27,1 24,9 7,0 3,3
Secondary 1998 32,1 46,0 10,5 9,2 2,3
Highest educational level
Higher 498 22,3 66,5 4,0 3,6 3,6
14 - 19 1117 27,7 35,4 25,6 9,2 2,1
20 - 24 1848 30,0 44,5 13,9 8,8 2,8
25 - 29 614 34,2 48,5 7,2 6,8 3,3
Age at birth
30+ 162 42,6 43,8 5,6 4,3 3,7
Muslim 3547 31,4 41,8 15,9 8,1 2,7
Christian 190 13,7 53,7 16,8 13,7 2,1
Religion
Missing 4 . . . . .
Total 3741 30,5 42,4 15,9 8,4 2,7
percentage of women who delivered in a home. Compared to the 20 - 24 years age group, a higher percentage of women between 14 and 20 years old deliver at home with a traditional birth attendant. The difference is 11.7 percent points while the difference between the other two groups is only 6.7 points. With private facility deliveries it is a similar case. The percentage of women who delivers their first child in a private sector health facility is relatively small in the youngest age group. In every older age group the proportion of women who delivers in a private facility is larger than the younger group, except for the age group of thirty years and older. In this oldest age group the proportion of women who gave birth to their first child in a private health facility is 4.8 percent points less in comparison to the group 25-29 age at first birth.
Christian women do not seem to have an urge to deliver in a public health facility. 31.4 percent of the Muslim women deliver in a public facility, yet only 13.7 percent of the Christian women delivered in this type of health facility. Instead, more Christian women are giving birth at home while being assisted by a medically trained person. 13.7 percent compared to 8.1 percent of the Muslim women. Also the percentage of Christian women delivering in a private facility is higher than the percentage of Muslim woman giving birth over there (53.7 percent: 41.8 percent).
Table 5.4 shows that in the richest wealth group 64.7 percent of the women is reported to have delivered their first baby in a private health facility, while only 5.3 percent of them delivered at home. The poorest women mostly delivered at home, namely 43.9 percent of all poorest women. Except for the poorest, women in all wealth groups show the highest percentages for delivering in a private facility.
Table 5.4 Delivery care at first pregnancy by enabling resources of the mother N = 3741
Total Place of and attendant at first delivery
Public sector, doctor
Private sector, doctor
Home, traditional attendant
Home, medical
attendant Other
Enabling resources N % % % % %
Poorest 742 29,8 22,9 35,2 8,7 3,3
Poorer 750 29,1 34,5 20,5 13,1 2,8
Middle 763 32,9 41,2 14,3 10,1 1,6
Richer 805 33,8 49,2 8,3 6,2 2,5
Wealth index
Richest 699 26,6 64,7 1,6 3,7 3,4
Urban 1509 35,8 49,4 6,0 5,2 3,6
Type of place
of residence Rural 2232 27,0 37,7 22,6 10,6 2,1
Total 3741 30,6 42,4 15,9 8,4 2,7
Living in rural area does not reduce the popularity of private health facilities as a place of delivery, although the percentage of woman delivering at home is also relatively high in rural areas. 33.2 percent of the women in rural areas delivered at home, compared to only 11.2 percent of the women living in urban areas. Delivery in a public health facility has the second biggest proportions for both the urban women, namely 35.8 percent, as for the rural women, namely 27 percent.
5.3 Antenatal care during second pregnancy
When women are pregnant for a second time they still need to go for antenatal visit to find out if no problems are occurring. The WHO standard of at least four visits still counts. The percentages of women who did, or did not receive antenatal care are shown in figure 5.3. Most of the women, namely 60.4 percent, did receive four or more antenatal care examinations. The other women, namely 39.6 percent, did not go for an antenatal visit or did not go often enough.
Antenatal care during second pregnancy by the different predisposing characteristic is shown in table 5.5. When the level of education is higher, the percentage of women receiving antenatal care is also higher. The variety between the highest educated women and the uneducated women is 53.3 percent points. The largest difference occurs between the primary and secondary educated women, where the variety is 21.6 percent points.
4+ visits -4 visits
80 70 60 50 40 30 20 10 0
Percent
60,4 39,6
Figure 5.3 Antenatal care at second pregnancy N=3389
Table 5.5 Antenatal care at second pregnancy by predisposing characteristics of the mother N = 3389
Total
Antenatal care second preg
-4 visits 4+ visits
Predisposing characteristics N % %
No education 899 66,3 33,7
Primary 359 51,0 49,0
Secondary 1746 29,4 70,6
Highest educational level
Higher 385 13,0 87,0
14 – 19 176 55,7 44,3
20 – 24 1602 48,8 51,2
25 – 29 1264 30,8 69,2
30+ 347 21,3 78,7
Age at birth
Missing 1 . .
Muslim 3217 39,6 60,4
Christian 171 39,8 60,2
Religion
Missing 1 . .
Total 3389 39,6 60,4
Younger women who are pregnant for the second time are reported to receive less antenatal care, compared to the older women. The difference between women in the age group 20 - 24 and 25 29 is the largest, namely 18 percent points.
In relation to religion and antenatal care, the observations do not show a large difference within the two religions. The variation between Muslim and Christian women is only 0.2 percent points.
In table 5.6 the antenatal care according to the enabling resources is shown. The group of poorest people is the biggest group not receiving antenatal care. 65.3 percent did not have the minimum of four check ups. The richest group is the largest group that received antenatal care, 89.6 percent of them got four or more antenatal examinations. The poorer the wealth group, the larger the percentage of not receiving antenatal care during the second pregnancy. The variation between the poorest and richest group is 54.9 percent points.
Of the women living in rural areas about half of them did go for four or more antenatal visits during their second pregnancies, the other half did not. From the women living in urban areas 77.2 percent did receive four or more antenatal health checks. The other 22.8 percent did not receive these checks while having their second pregnancy. There is a difference of 27.9 percent points between the urban and rural women.
5.4 Delivery care during second pregnancy
The researched delivery care for second pregnancies focuses on the place of delivery and the person who assisted a woman during her child’s birth. The delivery could take place in a home, a public health facility or in a private health facility. The attendants can be medically trained, like a doctor, nurse or midwife or attend births based on other skills, in other words, traditional birth attendants.
Figure 5.4 shows at which places the studied women delivered and by whom they were assisted. From the sample of 3421 women, 10 percent delivered at home with a medically trained birth attendant and another 23.2 percent delivered their child at home while a
Table 5.6 Antenatal care at second pregnancy by enabling resources of the mother
N = 3389
Total
Antenatal care second preg
-4 visits 4+ visits
Enabling resources N % %
Poorest 700 65,3 34,7
Poorer 678 54,1 45,9
Middle 698 39,0 61,0
Richer 716 25,7 74,3
Wealth index
Richest 597 10,4 89,6
Urban 1351 22,8 77,2
Type of place
of residence Rural 2038 50,7 49,3
Total 3389 39,6 60,4
